The nurse is preparing to administer medications for an eight-month-old infant with heart failure. The infant has a blood pressure of 114/66 mm Hg, apical pulse of 88 beats/minute, and respirations of 30 breaths/minute.
Which medication should the nurse withhold until the healthcare provider is notified?
Digoxin.
Furosemide.
Hydralazine.
Enalapril.
The Correct Answer is A
For an eight-month-old infant with heart failure, the nurse should withhold digoxin if the infant's apical pulse is less than 90 beats/minute and notify the healthcare provider. In this case, the infant's apical pulse is 88 beats/minute, so the nurse should withhold the digoxin and notify the healthcare provider.
Furosemide ( B), hydralazine (C), and enalapril (D) do not have specific parameters for withholding based on the infant's vital signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
During the initial phase of treatment for osteomyelitis, the nurse should instruct the child and parent to ensure that there is no weight bearing on the affected extremity. This may require the use of assistive devices such as crutches or a wheelchair. Administering topical antibiotic therapy, providing passive range of motion exercises, and scheduling ice pack applications to the infected area are not appropriate interventions during the initial phase of treatment.
Topical antibiotics may be used later in the course of treatment, after the initial phase of intravenous antibiotics has been completed.
Passive range of motion exercises may be appropriate during the later phases of treatment to prevent joint contractures.
Ice pack applications may be appropriate for pain relief, but they are not a primary intervention for osteomyelitis.
Correct Answer is A
Explanation
The boy's reported symptoms may indicate stress or anxiety related to his school experience. By asking the boy to describe a typical day at school, the nurse can gather information about the child's interactions with teachers and peers, academic performance, and any other potential sources of stress. This information can be used to develop an appropriate plan of care that addresses the child's emotional and physical needs.
Comparing vital signs or conducting a neurological assessment may not provide useful information in this case, and counseling the parents to pay more attention to the child is not a recommended intervention without first identifying the underlying cause of the child's symptoms.
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